A client is being prepped for a surgical procedure and the nurse is reviewing the informed
consent with the client. The client asks, "Is there any other way to take care of this without
having surgery?" The nurse has a duty to first:
1) Reassure the client that the surgery is the best treatment option
2) Tell the client if they don't want the surgery, they don't have to have it
3) Notify the surgeon that the client has additional questions about alternatives to surgery
4) Call the surgeon and cancel the surgery until the consent form is signed - ANSWER 3
Rationale:
The client has a right to an explanation of the treatment and its expected results, anticipated
risks and benefits, possible alternative treatment options and all questions answered before
a consent form is signed. Remember, the client is not asking you for your opinion. The client
is asking about alternative treatments for the condition. Notify the appropriate health care
provider if the client needs additional information that you cannot answer. Once the client
has all the necessary information then they can decide not to sign the informed content and
cancel the surgery.
A nurse is named in a lawsuit. Which of these factors will offer the best protection for that
nurse in a court of law?
1) Clinical specialty certification by an accredited organization
1
,2) Complete and accurate documentation of assessments and interventions
3) Above-average performance reviews prepared by nurse manager
4) Sworn statement that health care provider orders were followed - ANSWER 2
Rationale:
The medical record is a legal document. Documentation should include all steps of the
nursing process; it must be complete, accurate, concise and in chronological order.
Inaccurate or incomplete documentation will raise red flags and may indicate the nurse
failed to meet the standards of care. The attorney will review the medical record with the
nurse before giving a deposition (sworn pretrial testimony). Above-average performance
reviews could be considered supporting information. Certification is an "extra" based on the
nurse's initiative; it is, however, unrelated to accurate charting.
The new graduate nurse interviews for a position in a nursing department of a large health
care agency that uses the approach of shared governance. Which of these statements best
illustrate the shared governance model?
1) Staff groups are appointed to discuss nursing practice and client education issues
2) Non-nurse managers supervise nursing staff in groups of units
3) Nursing departments share responsibility for client outcomes
4) An appointed board oversees any administrative decisions - ANSWER 3
Rationale:
2
, Shared governance or self-governance is a method of organizational design. It promotes
empowerment of nurses to give them responsibility for client care issues and outcomes with
other divisions in the agency.
The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on
a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that
apply.)
1) The UAP empties the indwelling catheter bag for the client who had a transurethral
resection of the prostate (TURP) yesterday
2) The UAP applies moisture barrier cream to the client's excoriated perianal area
3) The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to
ambulate in the hall
4) The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark
blue
5) The UAP assists a client, who had a total knee replacement two days ago, to shave using a
straight-edge razor - ANSWER 3, 4, 5
Rationale:
The UAP can perform a number of nursing tasks, such as emptying an indwelling urinary
catheter bag and applying moisture barrier cream after peri care. However, it is unsafe for
the UAP to ambulate a client who recently received an IV push narcotic. Although UAP can
shave clients, it is unsafe to shave someone using a straight-edge razor because a client who
had knee replacement surgery is probably taking an anticoagulant; only an electric razor
should be used. Pulse oximeter readings must be done on a finger that is warm and free
from dark fingernail polish.
3
consent with the client. The client asks, "Is there any other way to take care of this without
having surgery?" The nurse has a duty to first:
1) Reassure the client that the surgery is the best treatment option
2) Tell the client if they don't want the surgery, they don't have to have it
3) Notify the surgeon that the client has additional questions about alternatives to surgery
4) Call the surgeon and cancel the surgery until the consent form is signed - ANSWER 3
Rationale:
The client has a right to an explanation of the treatment and its expected results, anticipated
risks and benefits, possible alternative treatment options and all questions answered before
a consent form is signed. Remember, the client is not asking you for your opinion. The client
is asking about alternative treatments for the condition. Notify the appropriate health care
provider if the client needs additional information that you cannot answer. Once the client
has all the necessary information then they can decide not to sign the informed content and
cancel the surgery.
A nurse is named in a lawsuit. Which of these factors will offer the best protection for that
nurse in a court of law?
1) Clinical specialty certification by an accredited organization
1
,2) Complete and accurate documentation of assessments and interventions
3) Above-average performance reviews prepared by nurse manager
4) Sworn statement that health care provider orders were followed - ANSWER 2
Rationale:
The medical record is a legal document. Documentation should include all steps of the
nursing process; it must be complete, accurate, concise and in chronological order.
Inaccurate or incomplete documentation will raise red flags and may indicate the nurse
failed to meet the standards of care. The attorney will review the medical record with the
nurse before giving a deposition (sworn pretrial testimony). Above-average performance
reviews could be considered supporting information. Certification is an "extra" based on the
nurse's initiative; it is, however, unrelated to accurate charting.
The new graduate nurse interviews for a position in a nursing department of a large health
care agency that uses the approach of shared governance. Which of these statements best
illustrate the shared governance model?
1) Staff groups are appointed to discuss nursing practice and client education issues
2) Non-nurse managers supervise nursing staff in groups of units
3) Nursing departments share responsibility for client outcomes
4) An appointed board oversees any administrative decisions - ANSWER 3
Rationale:
2
, Shared governance or self-governance is a method of organizational design. It promotes
empowerment of nurses to give them responsibility for client care issues and outcomes with
other divisions in the agency.
The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on
a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that
apply.)
1) The UAP empties the indwelling catheter bag for the client who had a transurethral
resection of the prostate (TURP) yesterday
2) The UAP applies moisture barrier cream to the client's excoriated perianal area
3) The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to
ambulate in the hall
4) The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark
blue
5) The UAP assists a client, who had a total knee replacement two days ago, to shave using a
straight-edge razor - ANSWER 3, 4, 5
Rationale:
The UAP can perform a number of nursing tasks, such as emptying an indwelling urinary
catheter bag and applying moisture barrier cream after peri care. However, it is unsafe for
the UAP to ambulate a client who recently received an IV push narcotic. Although UAP can
shave clients, it is unsafe to shave someone using a straight-edge razor because a client who
had knee replacement surgery is probably taking an anticoagulant; only an electric razor
should be used. Pulse oximeter readings must be done on a finger that is warm and free
from dark fingernail polish.
3
